Hand Disinfectant and COVID-19

Robin E. Ferner, University of Birmingham

 Dr Sudjoko Kuswadji (MSc(OM) NUS , PKK IDI, SpOk IDI)

● 1972 Fakultas Kedokteran Universitas Indonesia (Jakarta);

● 1974-1980 TNI AU Wamil (Halim, Kalijati, Timtim);
● 1980-1983 Tesoro Indonesia Migas (Tarakan);
● 1983-1996 Unocal Indonesia Migas (Balikpapan);
● 1987-1988 National University of Singapore COFM
● 1996-1999 Internasional Health Benefits Indonesia JPKM (Jakarta);
● 1999-2001 Sucofindo BUMN (Jakarta);
● 2001-2004 SOS International Kesehatan Kerja (Jakarta);
● 2005- sekarang trainer dan konsultan bebas (Jakarta);
World Health Organization
 WHO: How to handwash? With soap and water
https://www.youtube.com/watch?v=3PmVJQUCm4E
 Spectrum Health - Disease Prevention - Ultraviolet Light - Hand Washing
https://www.youtube.com/watch?v=KGIG82i5m0o
EFFECTIVE HANDWASHING Using Happy Birthday song (20 secs
minimum) #COVID19 #PANDEMIC #PREVENTION
https://www.youtube.com/watch?v=BH1oA8uUU1o
WASH YOUR HANDS to the HAPPY BIRTHDAY SONG | Proper Hand Washing Song
https://www.youtube.com/watch?v=JC7JnSkeyLM
Hand washing for fomites transmission
 Penyebaran virus Covid 19

• Droplets, ketika berbicara dan bernapas, lewat butir

droplets yang besar dan berat jatuh ke bawah pada jarak 50
cm;
• Yang kecil dan ringan (aerosol) terbang di udara lewat
batuk mencapai jarak 1-2 meter;
• Yang ringan (aerosol) bisa terbang dengan
menggumpal-gumpal (turbulence) mencapai jarak 8-9
meter;
Bernapas, bicara, batuk dan bersin
https://www.youtube.com/watch?v=piCWFgwysu0&feature=youtu.be
 Kesan...
• Virus dalam tubuh manusia sukar dikendalikan: tanpa
gejala, diagnosis, patofisiologi, obat, vaksin dst;
• Virus di luar tubuh lebih mudah dikendalikan, bisa dihitung
viral loadnya, antiseptik dst.
• Konsentrasi penanganan lebih banyak menyangkut
manusia, dengan segala macam kesulitannya;
• Protokol kesehatan mestinya protokol kesehatan dan
lingkungan;
• Perlu disusun program pengendalian Covid 19 dalam
lingkungan;
 Ignaz Philipp
Semmelweis

Semmelweis Ignác Fülöp; 1 July 1818 – 13

August 1865) was a Hungarian physician and
scientist, now known as an early pioneer of
antiseptic procedures.
Described as the "saviour of mothers",[2]
Semmelweis discovered that the incidence of
puerperal fever (also known as "childbed
fever") could be drastically cut by the use of
hand disinfection in obstetrical clinics.
Puerperal fever was common in
mid-19th-century hospitals and often fatal.
Semmelweis proposed the practice of
washing hands with chlorinated lime
solutions in 1847 while working in Vienna
General Hospital's First Obstetrical Clinic,
where doctors' wards had three times the
mortality of midwives' wards.[3]
He published a book of his findings in
Etiology, Concept and Prophylaxis of
Childbed Fever.
 Semmelweis, 1846

• Semmelweis showed that when physicians were made to

wash their hands in a chlorine solution, the mortality from
puerperal fever in the First Obstetric Ward in Vienna fell
from 459 in 1846 to 45 in 1848.

• By 1975, Graham Ayliffe in Birmingham had devised a way

of hand-washing that covered every part of the fingers and
hands.
 Graham Ayliffe described this as follows:

• “The preparation [of antiseptic detergent or liquid soap] was

applied for 30 seconds by a standard procedure, consisting of
five strokes backwards and forwards: palm to palm, right palm
over left dorsum, left palm over right dorsum, palm to palm with
fingers interlaced, backs of fingers to opposing palm with
fingers interlocked, rotational rubbing of right thumb clasped
over left palm and left thumb clasped over right palm, rotational
rubbing backwards and forwards with clasped fingers of right
hand in palm of left hand and clasped fingers of left hand in
palm of right hand; hands and wrists were rubbed until the end
of the 30-second period, then rinsed under a running tap for 15
seconds and dried, with two paper towels, for 15 seconds.”
 Hand washing studies...

• Initial studies of handwashing assessed efficacy by

observing the reduction in bacterial counts, using a
logarithmic scale.
• A reduction of 2 log units means that 99% of bacteria have
been removed, of 3 log units means that 99.9% of bacteria
have been removed, and so on.
• Test methods for viruses have been developed more
recently.
 Hand washing studies...

• Coronaviruses have a viral envelope, which makes them

potentially susceptible to surface-active agents such as
soap and alcohol.
• In vitro, several hand-rub products with an alcohol content
of at least 75% reduced SARS-CoV-1 virus load by at least 4
log units and wine vinegar and 70% ethanol reduced
SARS-CoV-1 load by more than 3 log units.
• It seems reasonable to extrapolate these results to
SARS-CoV-2.
 Hand washing studies...

• In a study of over 20,000 person-years, outpatient visits for

respiratory illness were 45% lower among army recruits
who washed their hand at least five times a day compared
with controls.
• Jefferson et al reviewed physical interventions to interrupt
or reduce the spread of respiratory viruses.
• They reported an odds ratio of 0.54 for respiratory
infections in those who washed their hands frequently,
compared with controls.
 Physical interventions to interrupt or reduce
the spread of respiratory viruses. Part 2 -
Hand hygiene and other hygiene measures:
systematic review and meta-analysis.

Al-Ansary L, Bawazeer GA, Beller, EM, Clark J, Conly JM, Del

Mar C, Dooley E, Ferroni E, Glasziou P, Hoffmann T, Jefferson
T, Thorning S, van Driel ML, Jones MA
Posted April 20, 2020
 OBJECTIVE:

• To assess the effectiveness of hand hygiene, surface

disinfecting, and other hygiene interventions in preventing
or reducing the spread of illnesses from respiratory
viruses.
 CONCLUSIONS:
Acute Aespiratory illness (ARI), Influenza-Like Illness (ILI)

• Despite the lack of evidence for the impact of hand hygiene

in reducing ILI and influenza, the modest evidence for
reducing the burden of ARIs, and related absenteeism,
justifies reinforcing the standard recommendation for hand
hygiene measures to reduce the spread of respiratory
viruses.
• Funding for relevant trials with an emphasis on adherence
and compliance with such a measure is crucial to inform
policy and global pandemic preparedness with confidence
and precision.
 Comparisons of different types of
hand hygiene interventions

• Five trials compared different hand hygiene interventions in

a variety of settings, such as schools, low-income
neighbourhoods and workplaces.
• There was considerable variation in interventions and
insufficient information in trial reports to enable
meta-analysis of these results (see Tables 1, 2 and 3 for
details of the trials, interventions and outcomes).
 Comparisons of different types of
hand hygiene interventions

• These trials looked at interventions such as soap and

water, hand sanitiser, body wash and skin wipes, with or
without additional hygiene education.
• One trial [41] compared different frequencies of
handwashing in a kindergarten and found that compulsory
handwashing every hour with an alcohol-based hand gel
reduced absenteeism due to ILI more than handwashing
every two hours or handwashing just before lunch.
 Comparisons of different types of
hand hygiene interventions
• Morton et al [42] showed that using an alcohol gel as an
adjunct to handwashing was more effective than
handwashing alone in a primary school setting.
• However, this was not confirmed in another trial where both
groups also received hygiene education [43].
• Savolainen-Kopra et al [44] found no difference between
soap and water and an alcohol-based hand rub.
• In low-income neighbourhoods in Pakistan, plain soap was
equally effective as antibacterial soap in preventing ARIs in
children aged under 5 years [45].
Questions to be
answered:
Though the studies reviewed make it clear that hand hygiene
has a modest effect, several questions remain unanswered.

• First, the high heterogeneity means there may be

substantial differences in the effect of different
interventions. The poor reporting limited our ability to
extract the information needed to assess any “dose
response” relationship.

• Second, the sustainability of hand washing is unclear:

some programmes achieved 5 to 10 hand washings per
day, but compliance may diminish with time, as motivation
decreases or because of adverse effects from frequent
hand washing.
Though the studies reviewed make it clear that hand hygiene
has a modest effect, several questions remain unanswered.

• Third, there is still little information on combinations of

hand washing with other interventions, and how those are
best introduced and sustained.

• Finally, and perhaps most importantly, most interventions

were intensive within small organisations, and the ability to
scale these up to national-level interventions is unclear.
 CONCLUSION

• The use of hand hygiene is an essential component of the

WHO recommendations for epidemic and pandemic
respiratory virus infections transmitted predominantly by
the droplet and contact route, along with strict adherence
with the use of personal protective equipment [79].
• The benefits of hand hygiene found in our study have
important implications for policymakers and support the
recommendations for hand hygiene in the current WHO
recommendations for COVID-19 [64].
 CONCLUSIONS
Combined effect of the trials is small, but highly statistically significant

• The combined effect of the trials is small, but highly statistically

significant.
• There is also considerable variation across trials, suggesting a
different impact across implementation methods and settings.
• More research is urgently needed into the sources of variability
of these effects.
• However, given the low cost and minimal disruption from good
hand washing behaviour, we believe this small effect warrants
continued promotion as part of a combined strategy to reduce
the spread of respiratory viruses.
• No single strategy - other than prolonged isolation of the entire
population - can block an epidemic spread.
 CONCLUSIONS
• The alternative is combining multiple, partially effective
interventions, such as hand washing, crowd reduction, or
self-isolation of symptomatic patients, etc.
• This model is used in medical error reduction, where a
common analogy is the "Swiss cheese model" whereby
enough slices of cheese are needed to prevent the holes
lining up, and an error occurring.
• Hand washing is clearly not a complete solution but adds
one important layer of a combined strategy to reduce
respiratory viral transmission.
The Swiss cheese model of
accident causation
Dante Orlandella and James T. Reason
of the University of Manchester
• The Swiss cheese model of accident causation is a model
used in risk analysis and risk management, including
aviation safety, engineering, healthcare, emergency service
organizations, and as the principle behind layered security,
as used in computer security and defense in depth.
Dante Orlandella and James T. Reason
of the University of Manchester
• It likens human systems to multiple slices of swiss cheese,
stacked side by side, in which the risk of a threat becoming
a reality is mitigated by the differing layers and types of
defenses which are "layered" behind each other.
• Therefore, in theory, lapses and weaknesses in one defense
do not allow a risk to materialize, since other defenses also
exist, to prevent a single point of failure.
Dante Orlandella and James T. Reason
of the University of Manchester
• The model was originally formally propounded by Dante
Orlandella and James T. Reason of the University of
Manchester,[1] and has since gained widespread
acceptance.
• It is sometimes called the "cumulative act effect".
 The Swiss cheese model of accident causation illustrates
that, although many layers of defense lie between hazards
and accidents, there are flaws in each layer that, if aligned,
can allow the accident to occur.
 Under the Swiss cheese model, each layer of protection
against loss has holes. By using multiple layers of defence,
the 'holes' in one layer may be covered by the 'cheese' in the
other layers but if the holes in different layers happen to
align, it is still possible for loss to occur
Pengendalian UV
Jika roti dipegang seperti ini mudah
berjamur
JASAD RENIK TIDAK NAMPAK
ALCOHOL BASED
 Special ultraviolet light-responsive
liquid = DETERJEN
• Step 1
• Firstly, our staff ensure they have thoroughly washed their hands
before placing their hands under the ultraviolet light.

• Step 2
• Next, they apply the special ultraviolet light-responsive liquid that
is located next to the UV machines to their hands, making sure
they are FULLY covered. This will allow the UV light to show any
remaining sources of dirt.
BOX UV ATAU BLB
 LIHAT LAGI DI UV BOX
• Step 3
• Once the UV-responsive liquid has been applied, they place their
hands under the UV light in the UV lightbox. They don't feel
anything – it’s just light.

• Step 4
• Next, they take a closer look at their hands and see if there are any
bright purple spots of UV light, these are areas of dirt. Here you
can see the handwashing was good – but not quite good enough.
SELA SELA BERCAK PUTIH
 SAMPAI BERSIH SEKALI

• Step 5
• They wash their hands again – even more thoroughly this time,
focusing on the areas that showed up under the UV light.

• Step 6
• They reapply the UV-responsive liquid to their hands and place
them back in the lightbox under the UV light like this.
LAMA MENCUCI TANGAN
MENILAI BERCAK
PUTIH
BAGIAN YANG MASIH KOTOR
SELA JARI SERING TERLUPAKAN
BAGIAN YANG TERLEWATKAN
GEMERLAP PUTIH BERKURANG
SABUN APA SAJA...
PERANAN SABUN
 Kesimpulan

• Mencuci tangan adalah upaya kesehatan murah dan mudah

dikerjakan, sudah banyak diteliti, meskipun tidak mutlak
bisa cegah Civid 19 tapi menjadi satu, dua lapisan keju
Swiss untuk cegah penularan.
• Banyak sekali cara mencuci, sukar distandarkan, waktu,
tempat di tangan, dengan UV dapat dilihat tingkat
kebersihan.
• Kualitas cuci tangan perlu diperhatikan, cuci tangan perlu
dipelajari, yang benar dan yang salah perlu dibedakan.